1. Wei Liu, BSN Penn State Nursing N 870
Endocarditis
Wei Liu, BSN
Penn State Nursing
N 870

2. Introduction
Endocarditis is inflammation of the inside lining of the heart chambers (endocardium) and heart valves
It is commonly caused by bacteria infection, therefore we refer it to infective endocarditis (IE)
IE is an uncommon, but not rare, disease. The annual incidence ranging from 3 to 7 per 100,000 person-years in the most contemporary population surveys.
IE continues to be characterized by increased morbidity and mortality and is now the third or fourth most common life-threatening infection syndrome, after sepsis, pneumonia, and intra-abdominal abscess.
(AHA, 2015)

3. Diagenosis
Infection of the endocardial surface of the heart, usually involving heart valves or an intracardiac device
Organisms: S. aureus, viridans streptococci, enterococci, and pseudomonas aeruginosa
Complications:
congestive heart failure,
arterial emboli,
myocardial infarction,
myocardial abscesses
death
( Sexton, 2015)

4. Pathogenesis Congenital or acquired heart condition
Alteration of the valvular endothelium leading to depositions of platelets and fibrin
Invasive procedures
Microorganisms in the circulating blood stream colonize on the damaged valvular surface or preexisting sterile vegetation
Microorganisms further propagate or enlarge the vegetation or cause systemic emboli
Further impeding blood flow and incite inflammation that involves the vegetation and adjacent endothelium
( Sexton, 2015)

6. ROS
PMH: prior endocarditis, prosthetic valve or cardiac device, valvular or congenital heart disease, rheumatic fever, IV drug use, IV lines, immunosuppression, recent dental/surgical procedure
fever and chills
fatigue
nausea and vomiting
weight lost and anorexia
aching muscles and joints
night sweats
headaches
shortness of breath and cough
skin lesions
hematuria
(NHLBI, 2010)

7. Physical Exam General: chills, fatigue, and paleness
vital signs: fever
Eyes: Roth spots
peripheral vascular: edema, clubbing, Splinter hemorrhages, Janeway lesions, and Osler's nodes
Cardiovascular: onset/changed heart murmur, pleuritic pain
Pulmonary: dyspnea, cough
Gastrointestinal: splenomegaly, pain and fullness
Neurological: confusion, sensory dysfunction

9. Diagnostic Tests blood cultures and echocardiography(TEE/TTE)
Sed rate, C-reactive-protein, urinalysis, WBC
modified Duke diagnosis criteria
definite endocarditis: 2 major criteria, 1 major criterion and 3 minor criteria, or 5 minor criteria
possible endocarditis: 1 major criterion and 1 minor criterion, or 3 minor criteria
The sensitivity of the Modified Duke Criteria is %, and the specificity is 93%
TEE has a substantially high sensitivity (76% to 100%) and specificity (94%), which is higher than TTE
(Loeb et al, 2011 & Baddour, et al, )

10. Modified Duke Criteria

11. Differential Diagnosis
Intravascular catheter infection
Skin and soft tissue infection
Cardiac device infection
Prosthetic joint infection
Sepsis
And many more…
This diagnosis of endocarditis (Red Flag) can be difficult to make, or the signs misleading, and there is a wide differential diagnosis to consider.
(Sexton, 2015)

12. Treatment
Antibiotic Therapy 4 to 6 weeks: based on the causative microorganism and its antibiotic susceptibility, and whether the involved valve is native or prosthetic.
Initial empiric therapy- Vancomycin or Ampicillin/Sulbactam (Unasyn) plus an Aminoglycoside (plus rifampin in patients with prosthetic valves)
Native Valve Endocarditis associates with staphylococci - Nafcillin and Gentamicin
Prosthetic Valve Endocarditi associate MRSA or coagulase-negative staphylococci - Vancomycin, Rifampin and Gentamicin
Vancomycin intolerance or resistant organisms -Linezolid or Daptomycin
(Baddour, et al, 2015 )

13. Treatment Con't
Surgical Therapy: patients with structural and functional damaged cardiac valves.
Anticoagulation: controversial
American Heart Association endocarditis treatment guidelines 2015:

14. Patient Education/Follow up
intravenous catheters should be removed promptly after antibiotic therapy
Monitor recurrent IE among intravenous drug abusers
echocardiography should be performed to establish a new baseline
monitored for complications such as valvular dysfunction, congestive heart failure, renal failure, and embolic phenomenon
provide information about daily dental hygiene; regular visits to the dentist; and the need for antibiotic prophylaxis for certain procedures
(Pierce et, al, 2012)

15. Outcomes
most of patients are able to recover with appropriate antimicrobial therapy.
The risk of embolization declines after institution of appropriate treatment.
in-hospital mortality rate is 18 to 23%; the six-month mortality rate is 22 to 27%
Complications: valvular dysfunction, congestive heart failure, renal failure, and embolic phenomenon
(Spelman & Sexton, 2015) )

16. Reference:
Baddour, L. M., Wilson, W. R., Bayer A. S., Fowler, V. G., Tleyjeh, I. M., Rybak M.J., et al. (2015). Infective endocarditis in adults: diagnosis, antimicrobial therapy, and management of complications: a scientific statement for healthcare professionals from the American Heart Association. Circulation. 132(15), P
Goroll, A. H., & Mulley, A. G. (2006). Primary care medicine: office evaluation and management of the adult patient. Philadelphia: Lippincott Williams & Wilkins.
Loeb, M., Smaill, F., & Smieja, M. (2011). Evidence based infectious diseases. 2nd ed. Chichester: Wiley-Blackwel.
National heart lung and blood institute (NHLBI). (2010). What is endocarditis. Retrieved from
Pierce, D., Calkins, B. C., & Thornton, K. (2012). Infectious endocarditis: diagnosis and treatment. American Family Physician, 85(10), p
Sexton, D. J. (2015) Pathogenesis of vegetation formation in infective endocarditis. UpToDate. Retrieved from
Spelman, D., & Sexton, D. (2015). Complications and outcome of infective endocarditis. UpToDate. Retrieved from

17. Questions?